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Hundt M, Chen A, Donovan J, Kim N, Yilma M, Tana M, Mehta N, Zhou K. Barriers to liver transplant referral in safety net settings: A national provider survey. Liver Transpl 2024; 30:896-906. [PMID: 38687168 DOI: 10.1097/lvt.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 04/12/2024] [Indexed: 05/02/2024]
Abstract
Safety net systems care for patients with a high burden of liver disease yet experience many barriers to liver transplant (LT) referral. This study aimed to assess safety net providers' perspectives on barriers to LT referrals in the United States. We conducted a nationwide anonymous online survey of self-identified safety net gastroenterologists and hepatologists from March through November 2022. This 27-item survey was disseminated via e-mail, society platforms, and social media. Survey sections included practice characteristics, transplant referral practices, perceived multilevel barriers to referral, potential solutions, and respondent characteristics. Fifty complete surveys were included in analysis. A total of 60.0% of respondents self-identified as White and 54.0% male. A total of 90.0% practiced in an urban setting, 82.0% in tertiary medical centers, and 16.0% in community settings, with all 4 US regions represented. Perceived patient-level barriers ranked as most significant, followed by practice-level, then provider-level barriers. Patient-level barriers such as lack of insurance (72.0%), finances (66.0%), social support (66.0%), and stable housing/transportation (64.0%) were ranked as significant barriers to referral, while medical mistrust and lack of interest were not. Limited access to financial services (36.0%) and addiction/mental health resources (34.0%) were considered important practice-level barriers. Few reported existing access to patient navigators (12.0%), and patient navigation was ranked as most likely to improve referral practices, followed by an expedited/expanded pathway for insurance coverage for LT. In this national survey, safety net providers reported the highest barriers to LT referral at the patient level and practice level. These data can inform the development of multilevel interventions in safety net settings to enhance equity in LT access for vulnerable patients.
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Affiliation(s)
- Melanie Hundt
- Department of Medicine, Los Angeles General Hospital, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ariana Chen
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - John Donovan
- Department of Medicine, Los Angeles General Hospital, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Nicole Kim
- Department of Medicine, University of Washington, Seattle, Washington
| | - Mignote Yilma
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Michele Tana
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
- Zuckerberg San Francisco General Hospital & Trauma Center, San Francisco, California, USA
- University of California San Francisco Liver Center, San Francisco, California, USA
| | - Neil Mehta
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Kali Zhou
- Department of Medicine, Los Angeles General Hospital, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Xu XS, Liu T, Chen YJ, Wu XY, Cheng MX, Li JZ. MSR1-dependent efferocytosis improved ischemia-reperfusion injury following aged-donor liver transplantation in mice by regulating the pro-resolving polarisation of macrophages. Exp Cell Res 2024; 442:114212. [PMID: 39168433 DOI: 10.1016/j.yexcr.2024.114212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 08/09/2024] [Accepted: 08/13/2024] [Indexed: 08/23/2024]
Abstract
Compared with young liver donors, aged liver donors are more susceptible to ischemia-reperfusion injury (IRI) following transplantation, which may be related to excessive inflammatory response and macrophage dysfunction, but the specific mechanism is unclear. Macrophage scavenger receptor 1 (MSR1) is a member of the scavenger receptor family, and plays an important regulatory role in inflammation response and macrophage function regulation. But its role in IRI following aged-donor liver transplantation is still unclear. This study demonstrates that MSR1 expression is decreased in macrophages from aged donor livers, inhibiting their efferocytosis and pro-resolving polarisation. Decreased MSR1 is responsible for the more severe IRI suffered by aged donor livers. Overexpression of MSR1 using F4/80-labelled AAV9 improved intrahepatic macrophage efferocytosis and promoted pro-resolving polarisation, ultimately ameliorating IRI following aged-donor liver transplantation. In vitro co-culture experiments further showed that overexpression of MSR1 promoted an increase in calcium concentration, which further activated the PI3K-AKT-GSK3β pathway, and induced the upregulation of β-catenin. Overall, MSR1-dependent efferocytosis promoted the pro-resolving polarisation of macrophages through the PI3K-AKT-GSK3β pathway-induced up-regulating of β-catenin leading to improved IRI following aged-donor liver transplantation.
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Affiliation(s)
- Xue-Song Xu
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Tao Liu
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Ya-Jun Chen
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xin-Yi Wu
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Ming-Xiang Cheng
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China.
| | - Jin-Zheng Li
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China.
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Jones O, Li Z, Magyar CTJ, Goldaracena N, Sayed BA, Ghanekar A, Cattral M, Selzner N, Sapisochin G. A scoping review of nonmedical barriers to living donor liver transplant. Liver Transpl 2024:01445473-990000000-00450. [PMID: 39190370 DOI: 10.1097/lvt.0000000000000473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 08/15/2024] [Indexed: 08/28/2024]
Abstract
This study aims to identify and categorize nonmedical barriers encountered by recipients, donors, and health care providers in the context of living donor liver transplantation (LDLT). Liver transplantation is vital for individuals with liver failure, yet high mortality rates on the transplant waitlist persist. LDLT was introduced to address deceased donor organ shortages; however, its adoption varies widely across regions, prompting the need to explore barriers hindering its implementation. The scoping review employed inclusion and exclusion criteria to identify studies focusing on nonmedical barriers to LDLT in both adult and pediatric populations. Qualitative, quantitative, and mixed-method studies were considered, covering the period from January 2005 to February 2023. The review's search strategy was conducted in the Ovid MEDLINE and Ovid EMBASE databases. Studies meeting the criteria were assessed for their characteristics and findings, which were synthesized into recipient, donor, and provider-level barriers. Among 2394 initially screened articles, 17 studies were eligible for inclusion. Recipient-level barriers encompassed systemic disparities in access, limited social support, immigration status, and inadequate awareness of LDLT. Donor-level barriers involved surgery-related risks, recovery time concerns, financial burdens, and religious beliefs. Provider-level barriers highlighted institutional support inadequacies and specialized surgeon shortages. The scoping review underscores nonmedical barriers to LDLT across recipient, donor, and provider levels. These barriers include socioeconomic disparities, information gaps, and inadequate institutional support. The findings underscore the need for comprehensive national efforts to raise awareness about LDLT and provide essential financial support.
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Affiliation(s)
- Owen Jones
- Ajmera Transplant Centre, HBP & Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Zhihao Li
- Ajmera Transplant Centre, HBP & Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christian Tibor Josef Magyar
- Ajmera Transplant Centre, HBP & Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Goldaracena
- Department of Surgery, Division of Transplant Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Blayne A Sayed
- Ajmera Transplant Centre, HBP & Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Ajmera Transplant Centre, HBP & Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Mark Cattral
- Ajmera Transplant Centre, HBP & Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, HBP & Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Ajmera Transplant Centre, HBP & Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
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Li G, Zeng M, Yan Z, Cai S, Ma Y, Wang Y, Li S, Li Y, Zhong K, Xiao M, Fu G, Weng J, Gao Y. HDAC inhibitors support long-term expansion of porcine hepatocytes in vitro. Biomed Pharmacother 2024; 177:116973. [PMID: 38908204 DOI: 10.1016/j.biopha.2024.116973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 06/03/2024] [Accepted: 06/15/2024] [Indexed: 06/24/2024] Open
Abstract
Hepatocyte transplantation is an effective treatment for end-stage liver disease. However, due to the limited supply of human hepatocytes, porcine hepatocytes have garnered attention as a potential alternative source. Nonetheless, traditional primary porcine hepatocytes exhibit certain limitations in function maintenance and in vitro proliferation. This study has discovered that by using histone deacetylase inhibitors (HDACi), primary porcine hepatocytes can be successfully reprogrammed into liver progenitor cells with high proliferative potential. This method enables porcine hepatocytes to proliferate over an extended period in vitro and exhibit increased susceptibility in lentivirus-mediated gene modification. These liver progenitor cells can readily differentiate into mature hepatocytes and, upon microencapsulation transplantation into mice with acute liver failure, significantly improve the survival rate. This research provides new possibilities for the application of porcine hepatocytes in the treatment of end-stage liver disease.
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Affiliation(s)
- Guanhong Li
- Department of Hepatobiliary Surgery II, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China; Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China; Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Southern Medical University, Guangzhou 510000, China
| | - Min Zeng
- Department of Hepatobiliary Surgery II, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China; Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China
| | - Zhengming Yan
- Department of Hepatobiliary Surgery II, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China; Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China
| | - Shaoru Cai
- Department of Hepatobiliary Surgery II, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China
| | - Yi Ma
- Department of Hepatobiliary Surgery II, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China; Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China
| | - Yuting Wang
- Department of Hepatobiliary Surgery II, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China; Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China
| | - Shao Li
- Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China
| | - Yang Li
- Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China
| | - Kebo Zhong
- Department of Hepatobiliary Surgery II, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China
| | - Mingjia Xiao
- Department of Hepatobiliary Surgery, Quzhou People's Hospital, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou 324000, China.
| | - Gongbo Fu
- Department of Oncology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing 210000, China.
| | - Jun Weng
- Department of Endoscopy, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou 510000, China.
| | - Yi Gao
- Department of Hepatobiliary Surgery II, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China; Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510000, China; State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510000, China; Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Southern Medical University, Guangzhou 510000, China.
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5
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Pan CW, Guifarro D, Poudel A, Abboud Y, Kotwal V. Racial Disparities in Alcoholic Hepatitis Hospitalizations in the United States: Trends, Outcomes, and Future Projections. Dig Dis Sci 2024; 69:2808-2816. [PMID: 38811506 DOI: 10.1007/s10620-024-08462-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/20/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Alcoholic hepatitis (AH) is a serious complication of alcohol consumption with high morbidity and mortality, particularly in the United States where alcohol-related liver diseases rank as one of the leading causes of preventable death. Our study aims to analyze the morbidity and mortality of AH across racial groups and project hospitalization trends up to 2028, thereby informing public health initiatives. METHODS We conducted a cross-sectional study utilizing data from the Nationwide Inpatient Sample (NIS) spanning 2012 to 2021. The study population comprised hospitalizations identified using specific ICD-9-CM and ICD-10-CM codes for AH. We assessed hospitalizations, in-hospital mortality rates, length of stay (LOS), and morbidities related to alcoholic hepatitis adjusting for sociodemographic factors and hospital characteristics. Statistical analyses were performed using Stata and R software, employing logistic and linear regression analyses, and SARIMA models for forecasting. RESULTS Our results indicated a predominantly White cohort (68%), with a notable increase in AH hospitalizations among Hispanics (129.1% from 2012 to 2021). Racial disparities were observed in inpatient mortality, liver transplant accessibility, and the occurrence of in-hospital complications. The study forecasts a continued rise in hospitalizations across all racial groups, with Hispanics experiencing the sharpest increase. CONCLUSION Our study reveals a disproportionate rise in the AH burden among Hispanics with projections indicating a persistent upward trend through 2028. These findings highlight the need for targeted public health strategies and improved healthcare access to mitigate the increasing AH burden and address disparities in care and outcomes.
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Affiliation(s)
- Chun-Wei Pan
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA.
| | - Daniel Guifarro
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Ayusha Poudel
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Yazan Abboud
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Vikram Kotwal
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
- Division of Gastroenterology and Hepatology, Cook County Health and Hospitals System, Chicago, USA
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Ahmed O, Doyle MBM, Abouljoud MS, Alonso D, Batra R, Brayman KL, Brockmeier D, Cannon RM, Chavin K, Delman AM, DuBay DA, Finn J, Fridell JA, Friedman BS, Fritze DM, Ginos D, Goldberg DS, Halff GA, Karp SJ, Kohli VK, Kumer SC, Langnas A, Locke JE, Maluf D, Meier RPH, Mejia A, Merani S, Mulligan DC, Nibuhanupudy B, Patel MS, Pelletier SJ, Shah SA, Vagefi PA, Vianna R, Zibari GB, Shafer TJ, Orloff SL. Liver Transplant Costs and Activity After United Network for Organ Sharing Allocation Policy Changes. JAMA Surg 2024; 159:939-947. [PMID: 38809546 PMCID: PMC11137658 DOI: 10.1001/jamasurg.2024.1208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 02/11/2024] [Indexed: 05/30/2024]
Abstract
Importance A new liver allocation policy was implemented by United Network for Organ Sharing (UNOS) in February 2020 with the stated intent of improving access to liver transplant (LT). There are growing concerns nationally regarding the implications this new system may have on LT costs, as well as access to a chance for LT, which have not been captured at a multicenter level. Objective To characterize LT volume and cost changes across the US and within specific center groups and demographics after the policy implementation. Design, Setting, and Participants This cross-sectional study collected and reviewed LT volume from multiple centers across the US and cost data with attention to 8 specific center demographics. Two separate 12-month eras were compared, before and after the new UNOS allocation policy: March 4, 2019, to March 4, 2020, and March 5, 2020, to March 5, 2021. Data analysis was performed from May to December 2022. Main Outcomes and Measures Center volume, changes in cost. Results A total of 22 of 68 centers responded comparing 1948 LTs before the policy change and 1837 LTs postpolicy, resulting in a 6% volume decrease. Transplants using local donations after brain death decreased 54% (P < .001) while imported donations after brain death increased 133% (P = .003). Imported fly-outs and dry runs increased 163% (median, 19; range, 1-75, vs 50, range, 2-91; P = .009) and 33% (median, 3; range, 0-16, vs 7, range, 0-24; P = .02). Overall hospital costs increased 10.9% to a total of $46 360 176 (P = .94) for participating centers. There was a 77% fly-out cost increase postpolicy ($10 600 234; P = .03). On subanalysis, centers with decreased LT volume postpolicy observed higher overall hospital costs ($41 720 365; P = .048), and specifically, a 122% cost increase for liver imports ($6 508 480; P = .002). Transplant centers from low-income states showed a significant increase in hospital (12%) and import (94%) costs. Centers serving populations with larger proportions of racial and ethnic minority candidates and specifically Black candidates significantly increased costs by more than 90% for imported livers, fly-outs, and dry runs despite lower LT volume. Similarly, costs increased significantly (>100%) for fly-outs and dry runs in centers from worse-performing health systems. Conclusions and Relevance Based on this large multicenter effort and contrary to current assumptions, the new liver distribution system appears to place a disproportionate burden on populations of the current LT community who already experience disparities in health care. The continuous allocation policies being promoted by UNOS could make the situation even worse.
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Affiliation(s)
- Ola Ahmed
- Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Maria Bernadette Majella Doyle
- Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Marwan S. Abouljoud
- Transplant Institute and Hepatobiliary Surgery, Henry Ford Hospital Detroit, Detroit, Michigan
| | - Diane Alonso
- Intermountain Medical Center, Salt Lake City, Utah
| | - Ramesh Batra
- Yale New Haven Health Transplantation Center, New Haven, Connecticut
| | - Kenneth L. Brayman
- Division of Transplant Surgery, University of Virginia Health System, Charlottesville
| | | | - Robert M. Cannon
- Comprehensive Transplant Institute, University of Alabama, Tuscaloosa
| | - Kenneth Chavin
- Temple University Health System, Philadelphia, Pennsylvania
| | - Aaron M. Delman
- Department of Surgery, University Cincinnati Medical Center, Cincinnati, Ohio
| | - Derek A. DuBay
- Department of Transplant Surgery, Medical University of South Carolina, Charleston
| | - Jan Finn
- Midwest Transplant Network, Westwood, Kansas
| | - Jonathan A. Fridell
- Department of Abdominal Transplant Surgery, Indiana University Health Transplant Institute, Indianapolis
| | | | - Danielle M. Fritze
- Department of Transplant Surgery, University of Texas Health Science Center at San Antonio
| | - Derek Ginos
- Intermountain Medical Center, Salt Lake City, Utah
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Glenn A. Halff
- University of Texas Health Science Center at San Antonio
| | - Seth J. Karp
- Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Vivek K. Kohli
- Department of Transplant and Hepatobiliary Surgery, Integris Baptist Medical Center, Oklahoma City, Oklahoma
| | - Sean C. Kumer
- Division of Transplantation and Hepatobiliary Surgery, University of Kansas Health System, Kansas City
| | - Alan Langnas
- Division of Transplant Surgery, University of Nebraska Medical Center, Lincoln
| | - Jayme E. Locke
- Comprehensive Transplant Institute, University of Alabama, Tuscaloosa
| | - Daniel Maluf
- Division of Transplantation and Hepatobiliary Surgery, University of Maryland, Baltimore
| | - Raphael P. H. Meier
- Division of Transplantation and Hepatobiliary Surgery, University of Maryland, Baltimore
| | | | - Shaheed Merani
- Division of Transplant Surgery, University of Nebraska Medical Center, Lincoln
| | - David C. Mulligan
- Yale New Haven Health Transplantation Center, New Haven, Connecticut
| | | | - Madhukar S. Patel
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center/William P. Clements Jr. University Hospital, Dallas
| | - Shawn J. Pelletier
- Division of Transplant Surgery, University of Virginia Health System, Charlottesville
| | - Shimul A. Shah
- Department of Surgery, University Cincinnati Medical Center, Cincinnati, Ohio
| | - Parsia A. Vagefi
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center/William P. Clements Jr. University Hospital, Dallas
| | - Rodrigo Vianna
- University of Miami Transplant Institute, Miami, Florida
| | - Gazi B. Zibari
- Willis Knighton Advanced Surgery Center, Willis-Knighton Health System, Shreveport, Louisiana
| | | | - Susan L. Orloff
- Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Oregon Health & Science University, Portland
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Alachraf K, Tumin D, Hayes D, Benden C. xTrends in racial and ethnic disparities in pediatric lung transplantation in the United States. Pediatr Pulmonol 2024. [PMID: 38990104 DOI: 10.1002/ppul.27175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Racial and ethnic disparities in pediatric lung transplantation (LTx) related to the shifting cystic fibrosis (CF) population receiving highly effective modulator therapy (HEMT) has not been well investigated. METHODS The UNOS Registry was queried for patients age 1-25 years undergoing bilateral LTx between 1 January 2012 and 31 December 2021. Race and ethnicity were classified as non-Hispanic White, non-Hispanic Black, Hispanic, or none of the above. The primary outcome was posttransplant mortality. Trends in the association between race/ethnicity and mortality were examined using transplant year as a continuous variable and stratifying year based on introduction of HEMT (triple combination therapy) in November 2019. RESULTS In the study sample (N = 941), 7% of patients were non-Hispanic Black, 15% were Hispanic, and 2% were some other racial or ethnic group. One hundred (11%) received LTx after approval of triple combination therapy, and 407 (43%) died during follow-up. We identified a statistically significant disparity in mortality hazard (hazard ratio: 1.91; 95% confidence interval: 1.31, 2.80) in non-Hispanic Black compared to non-Hispanic White patients in the pre-triple combination therapy era. CONCLUSIONS We found higher mortality hazard among non-Hispanic Black compared to non-Hispanic White children undergoing LTx in the United States. Further monitoring of LTx outcomes to identify and address disparities is needed in the current era of triple combination therapy for CF.
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Affiliation(s)
- Kamel Alachraf
- Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
- Department of Academic Affairs, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Don Hayes
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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8
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Tanaka T, Lentine KL, Shi Q, Vander Weg M, Axelrod DA. Differential Impact of the UNOS Simultaneous Liver-kidney Transplant Policy Change Among Patients With Sustained Acute Kidney Injury. Transplantation 2024; 108:724-731. [PMID: 37677960 DOI: 10.1097/tp.0000000000004774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Simultaneous liver-kidney transplant (SLK) allocation policy in the United States was revised in August 2017, reducing access for liver transplant candidates with sustained acute kidney injury (sAKI) and potentially adversely impacting vulnerable populations whose true renal function is overestimated by commonly used estimation equations. METHODS We examined national transplant registry data containing information for all liver transplant recipients from June 2013 to December 2021 to assess the impact of this policy change using instrumental variable estimation based on date of listing. RESULTS Posttransplant survival was compared for propensity-matched patients with sAKI who were only eligible for liver transplant alone (LTA_post; n = 638) after the policy change but would have been SLK-eligible before August 2017, with similar patients who were previously able to receive an SLK (SLK; n = 319). Overall posttransplant patient survival was similar at 3 y (81% versus 80%; P = 0.9). However, receiving an SLK versus LTA increased survival among African Americans (87% versus 61% at 3 y; P = 0.029). A trend toward survival benefit from SLK versus LTA, especially later in the follow-up period, was observed in recipients ≥ age 60 (3-y survival: 84% versus 76%; P = 0.2) and women (86% versus 80%; P = 0.2). CONCLUSIONS The 2017 United Network for Organ Sharing SLK Allocation Policy was associated with reduced survival of African Americans with end-stage liver disease and sAKI and, potentially, older patients and women. Our study suggested the use of race-neutral estimation of renal function would ameliorate racial disparities in the SLK arena; however, further studies are needed to reduce disparity in posttransplant outcomes among patients with liver and kidney failure.
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Affiliation(s)
- Tomohiro Tanaka
- Division of Gastroenterology and Hepatology, University of Iowa Carver College of Medicine, Iowa City, IA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Krista L Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis University Hospital, St. Louis, MO
| | - Qianyi Shi
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Mark Vander Weg
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA
| | - David A Axelrod
- Division of Transplantation and Hepatobiliary Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
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9
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Ying X, Mathis WS, Kahn PA, Jesudian AB, Fortune BE, Brown RS. Disparities in travel time to liver transplantation centers in the United States. Liver Transpl 2024; 30:326-330. [PMID: 37796186 DOI: 10.1097/lvt.0000000000000280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Xiaohan Ying
- Department of Internal Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Walter S Mathis
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Peter A Kahn
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arun B Jesudian
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, New York, USA
| | - Brett E Fortune
- Montefiore-Albert Einstein College of Medicine, Division of Hepatology, Bronx, New York, USA
| | - Robert S Brown
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, New York, USA
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10
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Munir MM, Endo Y, Mehdi Khan MM, Woldesenbet S, Yang J, Washburn K, Limkemann A, Schenk A, Pawlik TM. Association of Neighborhood Deprivation and Transplant Center Quality with Liver Transplantation Outcomes. J Am Coll Surg 2024; 238:291-302. [PMID: 38050968 DOI: 10.1097/xcs.0000000000000905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Social determinants of health can impact the quality of liver transplantation (LT) care. We sought to assess whether the association between neighborhood deprivation and transplant outcomes can be mitigated by receiving care at high-quality transplant centers. STUDY DESIGN In this population-based cohort study, patients who underwent LT between 2004 and 2019 were identified in the Scientific Registry of Transplant Recipients. LT-recipient neighborhoods were identified at the county level and stratified into quintiles relative to Area Deprivation Index (ADI). Transplant center quality was based on the Scientific Registry of Transplant Recipients 5-tier ranking using standardized transplant rate ratios. Multivariable Cox regression was used to assess the relationship between ADI, hospital quality, and posttransplant survival. RESULTS A total of 41,333 recipients (median age, 57.0 [50.0 to 63.0] years; 27,112 [65.4%] male) met inclusion criteria. Patients residing in the most deprived areas were more likely to have nonalcoholic steatohepatitis, be Black, and travel further distances to reach a transplant center. On multivariable analysis, post-LT long-term mortality was associated with low- vs high-quality transplant centers (hazard ratio [HR] 1.19, 95% CI 1.07 to 1.32), as well as among patients residing in high- vs low-ADI neighborhoods (HR 1.25, 95% CI 1.16 to 1.34; both p ≤ 0.001). Of note, individuals residing in high- vs low-ADI neighborhoods had a higher risk of long-term mortality after treatment at a low-quality (HR 1.31, 95% CI 1.06 to 1.62, p = 0.011) vs high-quality (HR 1.12, 95% CI 0.83 to 1.52, p = 0.471) LT center. CONCLUSIONS LT at high-quality centers may be able to mitigate the association between posttransplant survival and neighborhood deprivation. Investments and initiatives that increase access to referrals to high-quality centers for patients residing in higher deprivation may lead to better outcomes and help mitigate disparities in LT.
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Affiliation(s)
- Muhammad Musaab Munir
- From the Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
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11
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Wahid N, Lee J, Rosenblatt R, Kaplan A, Tipirneni R, Fortune BE, Safford M, Brown RS. Affordable Care Act Medicaid expansion associated with increased liver transplant waitlist access without worsening mortality. Liver Transpl 2024; 30:20-29. [PMID: 37486623 DOI: 10.1097/lvt.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Abstract
It is unclear what impact Affordable Care Act (ACA) Medicaid expansion has had on the liver transplantation (LT) waitlist. We aimed to assess associations between ACA Medicaid expansion and LT waitlist outcomes. The United Network for Organ Sharing Standard Transplant Analysis and Research (UNOS STAR) database was queried for patients listed for LT between January 1, 2009, and December 31, 2018. Our primary outcome was waitlist mortality and our secondary outcomes included Medicaid use on the LT waitlist and transplant rate. States were divided into groups based on their expansion status and the study period was divided into 2 time intervals-pre-expansion and post-expansion. Difference-in-difference (DiD) models were created to assess the impacts of expansion on each of the outcomes and for racial/ethnic and sex groups. In total, 56,414 patients from expansion states and 32,447 patients from nonexpansion states were included. Three-year waitlist mortality decreased at a similar rate in both cohorts [DiD estimate: 0.1, (95% CI, -1.1, -1.4), p = 0.838], but Medicaid use increased [DiD estimate: +7.7, (95% CI, 6.7, 8.7), p < 0.001] to a greater degree in expansion states after expansion than nonexpansion states. Between the 2 time intervals, Medicaid use on the LT waitlist increased from 19.4% to 26.1% in expansion states but decreased from 13.4% to 12.1% in nonexpansion states. In patients on Medicaid, there was a slight increase in the 3-year transplant rate associated with Medicaid expansion [DiD estimate +5.0, (95% CI, 1.8, 8.3), p = 0.002], which may in part be explained by differences in patient characteristics. Medicaid expansion was associated with increased Medicaid use on the LT waitlist without worsening overall waitlist mortality or transplant rate, suggesting that lenient and widespread public health insurance may increase access to the LT waitlist without adversely affecting outcomes.
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Affiliation(s)
- Nabeel Wahid
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - Jihui Lee
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Russell Rosenblatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Alyson Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Renuka Tipirneni
- Department of Internal Medicine, Division of General Medicine, Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - Brett E Fortune
- Department of Medicine, Division of Hepatology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Monika Safford
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Robert S Brown
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
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12
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Cotter TG, Mitchell MC, Patel MJ, Anouti A, Lieber SR, Rich NE, Arab JP, Díaz LA, Louissaint J, Kerr T, Mufti AR, Hanish SI, Vagefi PA, Patel MS, VanWagner LB, Lee WM, O'Leary JG, Singal AG. Racial and Ethnic Disparities in Liver Transplantation for Alcohol-associated Liver Diseases in the United States. Transplantation 2024; 108:225-234. [PMID: 37340542 DOI: 10.1097/tp.0000000000004701] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Emerging data suggest disparities exist in liver transplantation (LT) for alcohol-associated liver disease (ALD). As the incidence of ALD increases, we aimed to characterize recent trends in ALD LT frequency and outcomes, including racial and ethnic disparities. METHODS Using United Network for Organ Sharing/Organ Procurement and Transplantation Network data (2015 through 2021), we evaluated LT frequency, waitlist mortality, and graft survival among US adults with ALD (alcohol-associated hepatitis [AH] and alcohol-associated cirrhosis [AAC]) stratified by race and ethnicity. We used adjusted competing-risk regression analysis to evaluate waitlist outcomes, Kaplan-Meier analysis to illustrate graft survival, and Cox proportional hazards modeling to identify factors associated with graft survival. RESULTS There were 1211 AH and 26 526 AAC new LT waitlist additions, with 970 AH and 15 522 AAC LTs performed. Compared with non-Hispanic White patients (NHWs) with AAC, higher hazards of waitlist death were observed for Hispanic (subdistribution hazard ratio [SHR] = 1.23, 95% confidence interval [CI]: 1.16-1.32), Asian (SHR = 1.22, 95% CI:1. 01-1.47), and American Indian/Alaskan Native (SHR = 1.42, 95% CI: 1.15-1.76) candidates. Similarly, significantly higher graft failures were observed in non-Hispanic Black (HR = 1.32, 95% CI: 1.09-1.61) and American Indian/Alaskan Native (HR = 1.65, 95% CI: 1.15-2.38) patients with AAC than NHWs. We did not observe differences in waitlist or post-LT outcomes by race or ethnicity in AH, although analyses were limited by small subgroups. CONCLUSIONS Significant racial and ethnic disparities exist for ALD LT frequency and outcomes in the United States. Compared with NHWs, racial and ethnic minorities with AAC experience increased risk of waitlist mortality and graft failure. Efforts are needed to identify determinants for LT disparities in ALD that can inform intervention strategies.
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Affiliation(s)
- Thomas G Cotter
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Mack C Mitchell
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Mausam J Patel
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Ahmad Anouti
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Sarah R Lieber
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, ON, Canada
| | - Luis Antonio Díaz
- Departmento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jeremy Louissaint
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Thomas Kerr
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Arjmand R Mufti
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Steven I Hanish
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Parsia A Vagefi
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Madhukar S Patel
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - William M Lee
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Jacqueline G O'Leary
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
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13
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Hart A, Schaffhausen CR, McKinney WT, Gonzales K, Perugini J, Snyder JJ, Ladin K. "You don't know what you don't know": A qualitative study of informational needs of patients, family members, and living donors to inform transplant system metrics. Clin Transplant 2024; 38:e15240. [PMID: 38289894 DOI: 10.1111/ctr.15240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 12/28/2023] [Accepted: 01/03/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Informational needs and potential use of transplant metrics, especially among patients, remain understudied and a critical component of the transplant community's commitment to patient-centered care. We sought to understand the perspectives and needs of patients, family members/caregivers, living donors, and deceased donor family members. METHODS We examined decision-making experiences and perspectives on the needs of these stakeholder groups for data about the national transplant system among 58 participants of 14 focus groups and 6 interviews. RESULTS Three major themes emerged: 1) informational priorities and unmet needs (transplantation system processes, long-term outcomes data, prelisting data, patient-centered outcomes, and ability to compare centers and regions); 2) challenges obtaining relevant and trustworthy information (patient burden and effort, challenges with medical jargon, and difficulty finding trustworthy information); and 3) burden of facing the unknown (stress and anxiety leading to difficulty processing information, challenges facing the transplant journey when you "don't know what you don't know"). CONCLUSION Patient, family member, and living donor participation in shared decision-making has been limited by inadequate access to patient-centered information. New metrics and patient-facing data presentations should address these content gaps using best practices to improve understanding and support shared decision-making.
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Affiliation(s)
- Allyson Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Division of Nephrology, Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Cory R Schaffhausen
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Warren T McKinney
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Division of Nephrology, Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Kristina Gonzales
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA
| | - Julia Perugini
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA
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14
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Nair DG, Weiskirchen R. Recent Advances in Liver Tissue Engineering as an Alternative and Complementary Approach for Liver Transplantation. Curr Issues Mol Biol 2023; 46:262-278. [PMID: 38248320 PMCID: PMC10814863 DOI: 10.3390/cimb46010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Acute and chronic liver diseases cause significant morbidity and mortality worldwide, affecting millions of people. Liver transplantation is the primary intervention method, replacing a non-functional liver with a functional one. However, the field of liver transplantation faces challenges such as donor shortage, postoperative complications, immune rejection, and ethical problems. Consequently, there is an urgent need for alternative therapies that can complement traditional transplantation or serve as an alternative method. In this review, we explore the potential of liver tissue engineering as a supplementary approach to liver transplantation, offering benefits to patients with severe liver dysfunctions.
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Affiliation(s)
- Dileep G. Nair
- Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry (IFMPEGKC), Rheinisch-Westfälische Technische Hochschule (RWTH) University Hospital Aachen, D-52074 Aachen, Germany
| | - Ralf Weiskirchen
- Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry (IFMPEGKC), Rheinisch-Westfälische Technische Hochschule (RWTH) University Hospital Aachen, D-52074 Aachen, Germany
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15
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Thomas K, Babajide O, Gichoya J, Newsome J. Disparities in Transplant Interventions. Tech Vasc Interv Radiol 2023; 26:100921. [PMID: 38123285 DOI: 10.1016/j.tvir.2023.100921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Kaesha Thomas
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Owosela Babajide
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Judy Gichoya
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA.
| | - Janice Newsome
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
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16
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Saberi B, Gurakar A, Tamim H, Schneider CV, Sims OT, Bonder A, Fricker Z, Alqahtani SA. Racial Disparities in Candidates for Hepatocellular Carcinoma Liver Transplant After 6-Month Wait Policy Change. JAMA Netw Open 2023; 6:e2341096. [PMID: 37917059 PMCID: PMC10623194 DOI: 10.1001/jamanetworkopen.2023.41096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/21/2023] [Indexed: 11/03/2023] Open
Abstract
Importance Racial disparities in liver transplant (LT) for hepatocellular carcinoma (HCC) may be associated with unequal access to life-saving treatment. Objective To quantify racial disparities in LT for HCC and mortality after LT, adjusting for demographic, clinical, and socioeconomic factors. Design, Setting, and Participants This cohort study was a retrospective analysis of United Network Organ Sharing/Organ Procurement Transplant Network (OPTN) data from 2003 to 2021. Participants were adult patients with HCC on the LT waiting list and those who received LT. Data were analyzed from March 2022 to September 2023. Exposures Race and time before and after the 2015 OPTN policy change. Main Outcomes and Measures Proportion of LT from wait-listed candidates, the proportion of waiting list removals, and mortality after LT. Results Among 12 031 patients wait-listed for LT with HCC (mean [SD] age, 60.8 [7.4] years; 9054 [75.3%] male; 7234 [60.1%] White, 2590 [21.5%] Latinx/o/a, and 1172 [9.7%] Black or African American), this study found that after the 2015 model of end-stage liver disease (MELD) exception policy changes for HCC (era 2), the overall proportion of LT for HCC across all races decreased while the proportion of dropouts on the LT waiting list remained steady compared with patients who did not have HCC. In Kaplan-Meier analysis, Asian patients demonstrated the lowest dropout rates in both era 1 and era 2 (1-year dropout, 16% and 17%, respectively; P < .001). In contrast, Black or African American patients had the highest dropout rates in era 1 (1-year dropout, 24%), but comparable dropout rates (23%) with White patients (23%) and Latinx/o/a patients in era 2 (23%). In both eras, Asian patients had the highest survival after LT (5-year survival, 82% for era 1 and 86% for era 2), while Black or African American patients had the worst survival after LT (5-year survival, 71% for era 1 and 79% for era 2). In the multivariable analysis for HCC LT recipients, Black or African American race was associated with increased risk of mortality in both eras, compared with White race (HR for era 1, 1.17; 95% CI, 1.05-1.35; and HR for era 2, 1.31; 95% CI, 1.10-1.56). Conclusions and Relevance This cohort study of LT candidates in the US found that after the 2015 MELD exception policy change for HCC, the proportion of LT for HCC had decreased for all races. Black or African American patients had worse outcomes after LT than other races. Further research is needed to identify the underlying causes of this disparity and develop strategies to improve outcomes for HCC LT candidates.
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Affiliation(s)
- Behnam Saberi
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ahmet Gurakar
- Johns Hopkins University, Division of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Hani Tamim
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Carolin V. Schneider
- Department of Internal Medicine III, Rheinisch Westfälisch Technische Hochschule Aachen University, Aachen, Germany
| | - Omar T. Sims
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Alan Bonder
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Zachary Fricker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Saleh A. Alqahtani
- Johns Hopkins University, Division of Gastroenterology and Hepatology, Baltimore, Maryland
- Liver Transplant Center, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
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17
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Wang RX, Abu-Gazala S, Mahmud N. Posttransplant outcomes and trends in use of COVID-19-positive deceased donor liver transplantation. Liver Transpl 2023; 29:1129-1133. [PMID: 37162163 DOI: 10.1097/lvt.0000000000000175] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/04/2023] [Indexed: 05/11/2023]
Affiliation(s)
- Roy X Wang
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samir Abu-Gazala
- Division of Transplant Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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18
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Ross-Driscoll K, Gunasti J, Ayuk-Arrey AT, Adler JT, Axelrod D, McElroy L, Patzer RE, Lynch R. Identifying and understanding variation in population-based access to liver transplantation in the United States. Am J Transplant 2023; 23:1401-1410. [PMID: 37302576 PMCID: PMC10529375 DOI: 10.1016/j.ajt.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/04/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
We aimed to identify variations in liver transplant access across transplant referral regions (TRRs), accounting for differences in population characteristics and practice environments. Adult end-stage liver disease (ESLD) deaths and liver waitlist additions from 2015 to 2019 were included. The primary outcome was listing-to-death ratio (LDR). We modeled the LDR as a continuous variable and obtained adjusted LDR estimates for each TRR, accounting for clinical and demographic characteristics of ESLD decedents, socioeconomic and health care environment within the TRR, and characteristics of the transplant environment. The overall mean LDR was 0.24 (range: 0.10-0.53). In the final model, proportion of patients living in poverty and concentrated poverty was negatively associated with LDR; organ donation rate was positively associated with LDR. The R2 was 0.60, indicating that 60% of the variability in LDR was explained by the model. Approximately 40% of this variation remained unexplained and may be due to transplant center behaviors amenable to intervention to improve access to care for patients with ESLD.
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Affiliation(s)
- Katie Ross-Driscoll
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Jonathan Gunasti
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arrey-Takor Ayuk-Arrey
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joel T Adler
- Division of Abdominal Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - David Axelrod
- Solid Organ Transplant Center, Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Lisa McElroy
- Division of Abdominal Transplantation, Department of Surgery and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Raymond Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
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19
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Jones PD, Lai JC, Bajaj JS, Kanwal F. Actionable Solutions to Achieve Health Equity in Chronic Liver Disease. Clin Gastroenterol Hepatol 2023; 21:1992-2000. [PMID: 37061105 PMCID: PMC10330625 DOI: 10.1016/j.cgh.2023.03.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/08/2023] [Accepted: 03/26/2023] [Indexed: 04/17/2023]
Abstract
There are well-described racial and ethnic disparities in the burden of chronic liver diseases. Hispanic persons are at highest risk for developing nonalcoholic fatty liver disease, the fastest growing cause of liver disease. Hepatitis B disproportionately affects persons of Asian or African descent. The highest rates of hepatitis C occur in American Indian and Alaskan Native populations. In addition to disparities in disease burden, there are also marked racial and ethnic disparities in access to treatments, including liver transplantation. Disparities also exist by gender and geography, especially in alcohol-related liver disease. To achieve health equity, we must address the root causes that drive these inequities. Understanding the role that social determinants of health play in the disparate health outcomes that are currently observed is critically important. We must forge and/or strengthen collaborations between patients, community members, other key stakeholders, health care providers, health care institutions, professional societies, and legislative bodies. Herein, we provide a high-level review of current disparities in chronic liver disease and describe actionable strategies that have potential to bridge gaps, improve quality, and promote equity in liver care.
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Affiliation(s)
- Patricia D Jones
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Jasmohan S Bajaj
- Virginia Commonwealth University and Central Virginia Veterans Health Care System, Richmond, Virginia
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas
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20
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Abu S, Chen PH, Harris CM. Comparisons between White and Black Patients Hospitalized with Postliver Transplant Complications/Failure. South Med J 2023; 116:524-529. [PMID: 37400095 DOI: 10.14423/smj.0000000000001578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
OBJECTIVES The impact of race on patients presenting to North American hospitals with postliver transplant complications/failure (PLTCF) has not been studied fully. We compared in-hospital mortality and resource utilization outcomes between White and Black patients hospitalized with PLTCF. METHODS This was a retrospective cohort study that evaluated the years 2016 and 2017 from the National Inpatient Sample. Regression analysis was used to determine in-hospital mortality and resource utilization. RESULTS There were 10,805 hospitalizations for adults with liver transplants who presented with PLTCF. White and Black patients with PLTCF made up 7925 (73.3%) hospitalizations from this population. Among this group, 6480 were White (81.7%) and 1445 were Black (18.2%). Blacks were younger than Whites (mean age ± standard error of the mean: 46.8 ± 1.1 vs 53.6 ± 0.39 years, P < 0.01). Blacks were more likely to be female (53.9% vs 37.4%, P < 0.01). Charlson Comorbidity Index scores were not significantly different (scores ≥3: 46.7% vs 44.2%, P = 0.83). Blacks had significantly higher odds for in-hospital mortality (adjusted odds ratio 2.9, confidence interval [CI] 1.4-6.1; P < 0.01). Hospital charges were higher for Blacks compared with Whites (adjusted mean difference $48,432; 95% CI $2708-$94,157, P = 0.03). Blacks had significantly longer lengths of hospital stays (adjusted mean difference 3.1 days, 95% CI 1.1-5.1, P < 0.01). CONCLUSIONS Compared with White patients hospitalized for PLTCF, Black patients had higher in-hospital mortality and resource use. Investigation into causes leading to this health disparity is needed to improve in-hospital outcomes.
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21
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Hu XH, Chen L, Wu H, Tang YB, Zheng QM, Wei XY, Wei Q, Huang Q, Chen J, Xu X. Cell therapy in end-stage liver disease: replace and remodel. Stem Cell Res Ther 2023; 14:141. [PMID: 37231461 DOI: 10.1186/s13287-023-03370-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 04/26/2023] [Indexed: 05/27/2023] Open
Abstract
Liver disease is prevalent worldwide. When it reaches the end stage, mortality rises to 50% or more. Although liver transplantation has emerged as the most efficient treatment for end-stage liver disease, its application has been limited by the scarcity of donor livers. The lack of acceptable donor organs implies that patients are at high risk while waiting for suitable livers. In this scenario, cell therapy has emerged as a promising treatment approach. Most of the time, transplanted cells can replace host hepatocytes and remodel the hepatic microenvironment. For instance, hepatocytes derived from donor livers or stem cells colonize and proliferate in the liver, can replace host hepatocytes, and restore liver function. Other cellular therapy candidates, such as macrophages and mesenchymal stem cells, can remodel the hepatic microenvironment, thereby repairing the damaged liver. In recent years, cell therapy has transitioned from animal research to early human studies. In this review, we will discuss cell therapy in end-stage liver disease treatment, especially focusing on various cell types utilized for cell transplantation, and elucidate the processes involved. Furthermore, we will also summarize the practical obstacles of cell therapy and offer potential solutions.
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Affiliation(s)
- Xin-Hao Hu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, China
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Lan Chen
- Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Hao Wu
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, 310003, China
| | - Yang-Bo Tang
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, 310003, China
| | - Qiu-Min Zheng
- Life Sciences Institute, Zhejiang University, Hangzhou, 310058, China
| | - Xu-Yong Wei
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Qiang Wei
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Qi Huang
- Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Jian Chen
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China.
| | - Xiao Xu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, China.
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China.
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22
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Payani E, Börner N, Kolliogiannis D, Brunner S, Klein I, Ehmer U, Denk G, Lange CM, Ograja K, Dietrich P, Werner J, Guba M. Regional transplant rates depend more on physician-dependent variables than on proximity to transplant center. Langenbecks Arch Surg 2023; 408:191. [PMID: 37171640 PMCID: PMC10181954 DOI: 10.1007/s00423-023-02874-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/30/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE The objective of this work was to uncover inequalities in access to liver transplantation in Bavaria, Germany. METHODS For this purpose, the annual transplantation rate per 1 million inhabitants for the respective districts was determined from the aggregated postal codes of the place of residence of transplanted patients. The variables examined were proximity and travel time to the nearest transplant center, as well as the care category of the regional hospital. In addition, we assessed whether the head of gastroenterology at the regional hospital through which liver transplant candidates are referred was trained at a liver transplant center. RESULTS We could not demonstrate a direct relationship between proximity or travel time to the nearest transplant center and access to liver transplantation. Multivariate regression analysis shows that liver transplant training (p < 0.0001) of the chief physician (gastroenterologist) of the regional hospital was the most decisive independent factor for access to liver transplantation within a district. CONCLUSION We show that the transplant training experience of the head of gastroenterology at a regional hospital is an independent factor for the regional transplantation rate. Therefore, it appears important to maintain some liver transplant expertise outside the transplant centers in order to properly identify and assign potential transplant candidates for transplantation.
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Affiliation(s)
- Elnaz Payani
- Department of General, Visceral and Transplant Surgery, LMU Klinikum Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Nikolaus Börner
- Department of General, Visceral and Transplant Surgery, LMU Klinikum Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Dionysios Kolliogiannis
- Department of General, Visceral and Transplant Surgery, LMU Klinikum Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Stefan Brunner
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Ingo Klein
- Department of Surgery, University of Würzburg, Würzburg, Germany
| | - Ursula Ehmer
- Internal Medicine II, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | | | | | | | - Peter Dietrich
- Transplant Center Erlangen-Nürnberg, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, LMU Klinikum Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Markus Guba
- Department of General, Visceral and Transplant Surgery, LMU Klinikum Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany.
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23
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Hundt MA, Tien C, Kahn JA. Addressing sex-based disparities in liver transplantation. Curr Opin Organ Transplant 2023; 28:110-116. [PMID: 36437701 DOI: 10.1097/mot.0000000000001040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Disparities in access to liver transplantation by sex have been well described, disadvantaging women. Understanding the multifactorial causes of these disparities as well as the variety of proposed solutions is critical to improving access to this life-saving intervention for women. This review aims to summarize the current body of evidence on observed sex disparities in liver transplantation and highlight actionable, evidence-based mechanisms by which these disparities can be addressed. RECENT FINDINGS Strategies for addressing sex disparities in liver transplantation include increasing organ utilization, changing allocation policy, and leveraging public policies to reduce the incidence of end-stage liver disease. Several other promising interventions are currently being explored. SUMMARY In the United States, women face additional barriers to liver transplantation on the basis of sex. Immediate action is necessary to systematically address these inequities.
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Affiliation(s)
- Melanie A Hundt
- Division of Gastrointestinal and Liver Diseases
- Department of Medicine, University of Southern California, Los Angeles, California, USA
| | - Christine Tien
- Department of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jeffrey A Kahn
- Division of Gastrointestinal and Liver Diseases
- Department of Medicine, University of Southern California, Los Angeles, California, USA
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24
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Lee-Riddle GS, Samstein B. CAQ Corner: Evaluation and management of the living donor recipient. Liver Transpl 2023; 29:449-455. [PMID: 36746176 DOI: 10.1097/lvt.0000000000000096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/22/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Grace S Lee-Riddle
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medicine, New York, New York, USA
- Department of Surgery, Columbia University Medical Center, Division of Abdominal Organ Transplantation, New York, New York, USA
| | - Benjamin Samstein
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medicine, New York, New York, USA
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25
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Kaplan A, Wahid N, Fortune BE, Verna E, Halazun K, Samstein B, Brown RS, Rosenblatt R. Black patients and women have reduced access to liver transplantation for alcohol-associated liver disease. Liver Transpl 2023; 29:259-267. [PMID: 37160081 DOI: 10.1002/lt.26544] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 12/13/2022]
Abstract
Although sex and racial disparities for liver transplantation (LT) are known, it is unclear if disparities exist for patients with alcohol-associated liver disease (ALD). We aimed to compare sex and racial/ethnic differences in mortality, LT listing, and LT rates in patients with and without ALD. We analyzed patients who were listed for LT and/or died of end-stage liver disease (ESLD) between 2014 and 2018 using the United Network for Organ Sharing Standard Transplant Analysis and Research and Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research databases, respectively. Patients with ALD were compared with non-ALD patients. Our primary outcome was the ratio of listings for LT to deaths from ESLD-listing-to-death ratio (LDR)-a previously derived metric to assess access to the waiting list. Differences between sex and race/ethnicity were analyzed with chi-square tests and multivariable linear regression. There were 65,588 deaths and 16,133 listings for ALD compared with 75,020 deaths and 40,194 listings for non-ALD. LDR was lower for ALD (0.25 vs. 0.54; p < 0.001). Black patients had the lowest LDR in both ALD and non-ALD (0.13 and 0.39 for Black patients vs. 0.26 and 0.54 for White patients; p < 0.001). Women with ALD had a lower LDR (0.21 vs. 0.26; p < 0.001), whereas women without ALD had higher LDR than men (0.69 vs. 0.47; p < 0.001). There were significant negative interactions between women and ALD in LDR and the transplant-to-death ratio. Multivariable analysis and a sensitivity analysis, with more liberal definitions of ALD and non-ALD, confirmed these findings. Patients with ALD have lower access to LT. Among those with ALD, female and Black patients have the lowest access. New initiatives are needed to eliminate these inequities.
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Affiliation(s)
- Alyson Kaplan
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA
| | - Nabeel Wahid
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA
| | - Brett E Fortune
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA.,Center for Liver Disease and Transplantation , New York , New York , USA
| | - Elizabeth Verna
- Division of Digestive and Liver Disease , Columbia University Irving Medical Center , New York , New York , USA
| | - Karim Halazun
- Center for Liver Disease and Transplantation , New York , New York , USA.,Liver Transplant and Hepatobiliary Surgery , Weill Cornell Medical College , New York , New York , USA
| | - Benjamin Samstein
- Center for Liver Disease and Transplantation , New York , New York , USA.,Liver Transplant and Hepatobiliary Surgery , Weill Cornell Medical College , New York , New York , USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA.,Center for Liver Disease and Transplantation , New York , New York , USA
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA.,Center for Liver Disease and Transplantation , New York , New York , USA
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26
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Sakhuja S, Himes R, Carreker C, Guffey D, Beer S, Amin M, Hiremath G, Mysore K. Impact of psychosocial factors on medication level variability index and outcomes in pediatric liver transplant recipients. Pediatr Transplant 2023; 27:e14425. [PMID: 36325588 DOI: 10.1111/petr.14425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 09/20/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Caregivers play an important role in maintaining a functioning graft after pediatric liver transplantation. Therefore, the psychosocial factors of both patients and caregivers can have a critical impact on transplant outcomes. Appropriate assessment and recognition of these factors pre-transplantation may allow transplant teams to better define the needs of pediatric organ recipients and develop specific countermeasures, which may then contribute toward improving transplant outcomes. METHODS We studied 136 pediatric LT recipients followed at Texas Children's Hospital. Licensed social workers conducted comprehensive pre-transplant assessments on each patient, consisting of 22 psychosocial variables that were thought to impact adherence, which were reviewed during our study period. Non-adherence was determined using the MLVI for up to 4 years after transplantation. Biopsy-confirmed rejection episodes were assessed in the first 3 years after liver transplantation. RESULTS Factors significantly associated with non-adherence (defined as MLVI >2) included parental age and parental education level at assessment, type of insurance, and household income. The number of ACR episodes trended higher in patients with non-adherence, and these patients had a higher number of moderate to severe rejection episodes but this trend was not statistically significant. CONCLUSIONS Psychosocial characteristics such as parental age, education level, insurance, and household income may contribute significantly to suboptimal adherence to medications after transplantation. Identification of these psychosocial factors and early intervention is essential to the success and equitable care of our pediatric LT recipients.
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Affiliation(s)
- Shruti Sakhuja
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Ryan Himes
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ochsner Health, New Orleans, Louisiana, USA
| | - Colleen Carreker
- Department of Patient and Family Services, Texas Children's Hospital, Houston, Texas, USA
| | - Danielle Guffey
- Institution for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Stacey Beer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Mansi Amin
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Girish Hiremath
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Vanderbilt Children's, Nashville, Tennessee, USA
| | - Krupa Mysore
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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27
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Kerznerman S, Ford L, Kuns M, Florman S, Schiano T. Successful pathways to liver transplant for undocumented immigrants. Am J Transplant 2023; 23:459-463. [PMID: 36720314 DOI: 10.1016/j.ajt.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/24/2023] [Indexed: 01/30/2023]
Abstract
Liver transplant (LT) for undocumented immigrants presents numerous challenges. Although the United Network for Organ Sharing has implemented multiple policy changes to lessen the disparities in LT throughout the years, undocumented immigrants remain especially marginalized and disadvantaged when compared with other populations. Since 2013, the Mount Sinai Hospital's Recanati Miller Transplant Institute has transplanted 16 undocumented immigrants with successful outcomes. Here, we will share our experience of evaluating, caring for, and transplanting these patients and also highlight our team's mission to ensure that this population has equitable access to lifesaving medical treatment.
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Affiliation(s)
- Stanley Kerznerman
- Department of Social Work, The Mount Sinai Hospital, New York, New York, USA.
| | - Laura Ford
- Department of Social Work, The Mount Sinai Hospital, New York, New York, USA
| | - Mara Kuns
- Division of LegalHealth, The New York Legal Assistance Group, New York, New York, USA
| | - Sander Florman
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas Schiano
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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28
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Frasco PE, Mathur AK, Chang YH, Alvord JM, Poterack KA, Khurmi N, Bauer I, Aqel B. Days alive and out of hospital after liver transplant: comparing a patient-centered outcome between recipients of grafts from donation after circulatory and brain deaths. Am J Transplant 2023; 23:55-63. [PMID: 36695622 DOI: 10.1016/j.ajt.2022.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 01/13/2023]
Abstract
We retrospectively compared outcomes between recipients of donation after circulatory death (DCD) and donation after brain death (DBD) liver allografts using days alive and out of hospital (DAOH), a composite outcome of mortality, morbidity, and burden of care from patient perspective. The initial length of stay and duration of any subsequent readmission for the first year after liver transplantation were recorded. Donor category and perioperative and intraoperative characteristics pertinent to liver transplantation were included. The primary outcome was DAOH365. Secondary outcomes included early allograft dysfunction and hepatic arterial and biliary complications. Although the incidence of both early allograft dysfunction (P < .001) and ischemic cholangiopathy (P < .001) was significantly greater in the recipients of DCD, there were no significant differences in the length of stay and DAOH365. The median DAOH365 was 355 days for recipients of DBD allografts and 353 days for recipients of DCD allografts (P = .34). Increased transfusion burden, longer cold ischemic time, and non-White recipients were associated with decreased DAOH. There were no significant differences in graft failure (P = .67), retransplantation (P = .67), or 1-year mortality (P = .96) between the 2 groups. DAOH is a practical and attainable measure of outcome after liver transplantation. This metric should be considered for quality measurement and reporting in liver transplantation.
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Affiliation(s)
- Peter E Frasco
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA.
| | - Amit K Mathur
- Department of Transplantation Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Yu-Hui Chang
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jeremy M Alvord
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Karl A Poterack
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Isabel Bauer
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Bashar Aqel
- Department of Transplant Hepatology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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29
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Negri A, Wilson L. Future Systems of Xenotransplantation: Melding Historical and Bioethical Methodology. Cell Transplant 2023; 32:9636897231170510. [PMID: 37254850 PMCID: PMC10233605 DOI: 10.1177/09636897231170510] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 03/22/2023] [Accepted: 04/03/2023] [Indexed: 06/01/2023] Open
Abstract
The future of xenotransplantation is promising. However, the scientific process behind xenotransplantation, shown through the methodology of history and bioethics, involves stakeholders beyond the laboratory. We present three short vignettes, the history of a 20th-century pioneer in solid organ transplantation, the xenoheart received by David Bennett, and a global system of illegal organ procurement, to highlight the complexity of biomedical practice. Current solid organ transplantation systems are seemingly unsustainable and ineffective in satisfying a growing global demand for organs. Despite the shortcomings of current systems, we argue that the discourse surrounding xenotransplantation science is insufficient to construct a long-lasting and equitable replacement for solid organ transplantation. Xenotransplantation is more than a surgical technique, an interdisciplinary health concern, or a biomedical technology-it is deeply dependent on a series of cultural, historical, and social factors. Incorporating a greater variety of perspectives and disciplines into ongoing discussions of xenotransplantation science, while potentially frustrating in the short term, will act to maximize its potential as a paradigm-shifting science.
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Affiliation(s)
- Adam Negri
- History of Medicine, University of Minnesota,
Minneapolis, MN, USA
| | - Lauren Wilson
- Philosophy, University of Minnesota,
Minneapolis, MN, USA
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30
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Tsuang WM, Lopez R, Tang A, Budev M, Schold JD. Place-based heterogeneity in lung transplant recipient outcomes. Am J Transplant 2022; 22:2981-2989. [PMID: 35962587 PMCID: PMC11362981 DOI: 10.1111/ajt.17170] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/14/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
Place is defined as a social or environmental area of residence with meaning to a patient. We hypothesize there is an association between place and the clinical outcomes of lung transplant recipients in the United States. In a retrospective cohort study of transplants between January 1, 2010, and December 31, 2019, in the Scientific Registry of Transplant Recipients, multivariable Cox regression models were used to test the association between place (through social and environmental factors) with readmission, lung rejection, and survival. Among 18,465 recipients, only 20% resided in the same county as the transplant center. Recipients from the most socially vulnerable counties when compared to the least vulnerable were more likely to have COPD as a native disease, Black or African American race, and travel long distances to reach a transplant center. Higher local life expectancy was associated with lower likelihood for readmission (odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.84, 0.98, p = .01). Higher social vulnerability was associated with a higher likelihood of lung rejection (OR = 1.37, [CI]: 1.07, 1.76, p = .01). There was no association of residence with posttransplant survival. Recipient place-based factors were associated with complications and processes of care after transplant and warrant further investigation.
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Affiliation(s)
- Wayne M. Tsuang
- Respiratory institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rocio Lopez
- Center for Populations Health Research, Lerner Research institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anne Tang
- Center for Populations Health Research, Lerner Research institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marie Budev
- Respiratory institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jesse D. Schold
- Center for Populations Health Research, Lerner Research institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
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31
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Ebel NH, Lai JC, Bucuvalas JC, Wadhwani SI. A review of racial, socioeconomic, and geographic disparities in pediatric liver transplantation. Liver Transpl 2022; 28:1520-1528. [PMID: 35188708 PMCID: PMC9949889 DOI: 10.1002/lt.26437] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/21/2022] [Accepted: 02/15/2022] [Indexed: 02/07/2023]
Abstract
Equity is a core principle in both pediatrics and solid organ transplantation. Health inequities, specifically across race, socioeconomic position, or geography, reflect a moral failure. Ethical principles of prudential life span, maximin principle, and fair innings argue for allocation priority to children related to the number of life years gained, equal access to transplant, and equal opportunity for ideal posttransplant outcomes. Iterative policy changes have aimed to narrow these disparities to achieve pediatric transplant equity. These policy changes have focused on modifying pediatric priority for organ allocation to eliminate mortality on the pediatric transplant waiting list. Yet disparities remain in pediatric liver transplantation at all time points: from access to referral for transplantation, likelihood of living donor transplantation, use of exception narratives, waitlist mortality, and inequitable posttransplant outcomes. Black children are less likely to be petitioned for exception scores, have higher waitlist mortality, are less likely to be the recipient of a living donor transplant, and have worse posttransplant outcomes compared with White children. Children living in the most socioeconomically deprived neighborhoods have worse posttransplant outcomes. Children living farther from a transplant center have higher waitlist mortality. Herein we review the current knowledge of these racial and ethnic, socioeconomic, and geographic disparities for these children. To achieve equity, stakeholder engagement is required at all levels from providers and health delivery systems, learning networks, institutions, and society. Future initiatives must be swift, bold, and effective with the tripartite mission to inform policy changes, improve health care delivery, and optimize resource allocation to provide equitable transplant access, waitlist survival, and posttransplant outcomes for all children.
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Affiliation(s)
- Noelle H Ebel
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics Stanford University Stanford California USA Division of Gastroenterology, Hepatology & NutritionDepartment of Medicine University of California San Francisco California USA Division of Pediatric HepatologyDepartment of Pediatrics Icahn School of Medicine at Mount Sinai New York New York USA Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of PediatricsUniversity of CaliforniaSan Francisco California USA
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Uche-Anya E, Anyane-Yeboa A, Berzin TM, Ghassemi M, May FP. Artificial intelligence in gastroenterology and hepatology: how to advance clinical practice while ensuring health equity. Gut 2022; 71:1909-1915. [PMID: 35688612 DOI: 10.1136/gutjnl-2021-326271] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 04/19/2022] [Indexed: 12/12/2022]
Abstract
Artificial intelligence (AI) and machine learning (ML) systems are increasingly used in medicine to improve clinical decision-making and healthcare delivery. In gastroenterology and hepatology, studies have explored a myriad of opportunities for AI/ML applications which are already making the transition to bedside. Despite these advances, there is a risk that biases and health inequities can be introduced or exacerbated by these technologies. If unrecognised, these technologies could generate or worsen systematic racial, ethnic and sex disparities when deployed on a large scale. There are several mechanisms through which AI/ML could contribute to health inequities in gastroenterology and hepatology, including diagnosis of oesophageal cancer, management of inflammatory bowel disease (IBD), liver transplantation, colorectal cancer screening and many others. This review adapts a framework for ethical AI/ML development and application to gastroenterology and hepatology such that clinical practice is advanced while minimising bias and optimising health equity.
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Affiliation(s)
- Eugenia Uche-Anya
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Adjoa Anyane-Yeboa
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tyler M Berzin
- Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Marzyeh Ghassemi
- Institute for Medical and Evaluative Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Folasade P May
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA Kaiser Permanente Center for Health Equity and Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, California, USA
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33
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Gray C, Arney J, Clark JA, Walling AM, Kanwal F, Naik AD. The chosen and the unchosen: How eligibility for liver transplant influences the lived experiences of patients with advanced liver disease. Soc Sci Med 2022; 305:115113. [PMID: 35690034 DOI: 10.1016/j.socscimed.2022.115113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 02/07/2023]
Abstract
Advanced liver disease is often uncurable and fatal. Liver transplant is the only curative option for patients with advanced, irreversible liver disease, but the need for new livers far exceeds the supply. Patients with the greatest need as well as the greatest likelihood of benefit, based on a complex array of biomedical and psychosocial considerations, are prioritized for transplant. The opportunity to receive a life-saving surgery no doubt has enormous consequences for patients and their healthcare providers, as does the absence of that opportunity. But these consequences are poorly characterized, especially for patients deemed poor candidates for liver transplant. Through in-depth interviews with patients living with advanced liver disease and the providers who care for them, we explore how eligibility status affects illness experiences, including patients' interactions with clinicians, knowledge about their disease, expectations for the future, and efforts to come to terms with a life-limiting illness. We describe how the clinical and social requirements needed to secure eligibility for liver transplant lend themselves to a clinical and cultural logic that delineates "worthy" and "unworthy" patients. We describe how providers and candidates discuss the possibility of moral redemption for such patients through transplant surgeries, a discourse notably absent among patients not eligible for transplant.
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Affiliation(s)
- Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.
| | - Jennifer Arney
- Department of Sociology, University of Houston-Clear Lake, 2700 Bay Area Boulevard, Houston, TX, 77058, USA; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA.
| | - Jack A Clark
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA.
| | - Anne M Walling
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA; Department of Medicine, Division of General Internal Medicine and Health Services Research University of California at Los Angeles, 1100 Glendon Ave STE 850, Los Angeles, CA, 90024, USA.
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA; Department of Medicine, Health Services Research and Gastroenterology and Hepatology, Baylor College of Medicine, 7200 Cambridge St., Houston, TX, 77030, USA.
| | - Aanand D Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA; Department of Medicine, Department of Health Services Research, Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, TX 7200 Cambridge St., Houston, TX, 77030, USA.
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Ge J, Ku E, Roll GR, Lai JC. An Analysis of Free-Text Refusals as an Indicator of Readiness to Accept Organ Offers in Liver Transplantation. Hepatol Commun 2022; 6:1227-1235. [PMID: 34783178 PMCID: PMC9035557 DOI: 10.1002/hep4.1865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/13/2021] [Accepted: 10/30/2021] [Indexed: 11/15/2022] Open
Abstract
Racial/ethnic minorities experience higher rates of wait-list mortality and longer waiting times on the liver transplant wait list. We hypothesized that racial/ethnic minorities may encounter greater logistical barriers to maintaining "readiness" on the wait list, as reflected in offer nonacceptance. We identified all candidates who received an organ offer between 2009 and 2018 and investigated candidates who did not accept an organ offer using a free-text refusal reason associated with refusal code 801. We isolated patients who did not accept an organ offer due to "candidate-related logistical reasons" and evaluated their characteristics. We isolated 94,006 "no 801" patients and 677 "with 801 logistical" patients. Common reasons for offer decline among the 677 were 60% "unable to travel/distance," 22% "cannot be contacted," 13% "not ready/unspecified," and 5% "financial/insurance." Compared to "no 801," "with 801 logistical" patients were more likely to be Hispanic (19% vs. 15%, P < 0.01). Multivariate logistic modeling showed Hispanic (odds ratio [OR] 1.44, 95% confidence interval [CI] 1.17-1.76, P < 0.01) and multiracial/other ethnicity (OR 1.82, 95% CI 1.08-3.05, P = 0.02) were associated with "with 801 logistical" status. The "with 801 logistical" patients were listed with higher allocation (inclusive of exception points) Model for End-Stage Liver Disease scores (16 vs. 15, P < 0.01) and remained longer on the wait list (median 428 days vs. 187 days, P < 0.01). Conclusion: In this analysis of wait-list candidates, we isolated 677 patients who declined an organ offer with a free-text reason consistent with a "candidate-related logistical reason." Compared with non-Hispanic Whites, Hispanics were at 1.44 odds of not accepting organ offers due to logistical reasons. These limited findings motivate further research into interventions that would improve candidates' "readiness" to accept organ offers and may benefit racial/ethnic minorities on the liver-transplantation wait list.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California, San FranciscoSan FranciscoCAUSA
| | - Elaine Ku
- Division of NephrologyDepartment of MedicineUniversity of California, San FranciscoSan FranciscoCAUSA.,Division of Pediatric NephrologyDepartment of PediatricsUniversity of California, San FranciscoSan FranciscoCAUSA.,Department of Epidemiology and BiostatisticsUniversity of California, San FranciscoSan FranciscoCAUSA
| | - Garrett R Roll
- Division of Transplant SurgeryDepartment of SurgeryUniversity of California, San FranciscoSan FranciscoCAUSA
| | - Jennifer C Lai
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California, San FranciscoSan FranciscoCAUSA
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35
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Gurney J, Sarfati D, Stanley J, Kerrison C, Koea J. Equity of timely access to liver and stomach cancer surgery for Indigenous patients in New Zealand: a national cohort study. BMJ Open 2022; 12:e058749. [PMID: 35487720 PMCID: PMC9058766 DOI: 10.1136/bmjopen-2021-058749] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES When combined, liver and stomach cancers are second only to lung cancer as the most common causes of cancer death for the indigenous Māori population of New Zealand-with Māori also experiencing substantial disparities in the likelihood of survival once diagnosed with these cancers. Since a key driver of this disparity in survival could be access to surgical treatment, we have used national-level data to examine surgical procedures performed on Māori patients with liver and stomach cancers and compared the likelihood and timing of access with the majority European population. DESIGN, PARTICIPANTS AND SETTING We examined all cases of liver and stomach cancers diagnosed during 2007-2019 on the New Zealand Cancer Registry (liver cancer: 866 Māori, 2460 European; stomach cancer: 953 Māori, 3192 European) and linked these cases to all inpatient hospitalisations that occurred over this time to identify curative and palliative surgical procedures. As well as descriptive analysis, we compared the likelihood of access to a given procedure between Māori and Europeans, stratified by cancer and adjusted for confounding and mediating factors. Finally, we compared the timing of access to a given procedure between ethnic groups. RESULTS AND CONCLUSIONS We found that (a) access to liver transplant for Māori is lower than for Europeans; (b) Māori with stomach cancer appear more likely to require the type of palliation consistent with gastric outlet obstruction; and (c) differential timing of first stomach cancer surgery between Māori and European patients. However, we may also be cautiously encouraged by the fact that differences in overall access to curative surgical treatment were either marginal (liver) or absent (stomach).
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Affiliation(s)
- Jason Gurney
- Department of Public Health, University of Otago, Dunedin, New Zealand
| | - Diana Sarfati
- Te Aho o Te Kahu - Cancer Control Agency, Wellington, New Zealand
| | - James Stanley
- Department of Public Health, University of Otago, Dunedin, New Zealand
| | - Clarence Kerrison
- Endoscopy Department, Waikato District Health Board, Hamilton, New Zealand
| | - Jonathan Koea
- General Surgery Services, Waitemata District Health Board, Takapuna, New Zealand
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36
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Cramer SW, Do TH, Palzer EF, Naik A, Rice AL, Novy SG, Hanson JT, Piazza AN, Howard MA, Huling JD, Chen CC, McGovern RA. Persistent Racial Disparities in Deep Brain Stimulation for Parkinson's Disease. Ann Neurol 2022; 92:246-254. [PMID: 35439848 PMCID: PMC9546407 DOI: 10.1002/ana.26378] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 11/16/2022]
Abstract
We sought to determine whether racial and socioeconomic disparities in the utilization of deep brain stimulation (DBS) for Parkinson's disease (PD) have improved over time. We examined DBS utilization and analyzed factors associated with placement of DBS. The odds of DBS placement increased across the study period, whereas White patients with PD were 5 times more likely than Black patients to undergo DBS. Individuals, regardless of racial background, with 2 or more comorbidities were 14 times less likely to undergo DBS. Privately insured patients were 1.6 times more likely to undergo DBS. Despite increasing DBS utilization, significant disparities persist in access to DBS. ANN NEUROL 2022;92:246–254
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Affiliation(s)
- Samuel W Cramer
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN
| | - Truong H Do
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN
| | - Elise F Palzer
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, IL
| | | | | | - Jacob T Hanson
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN
| | | | | | - Jared D Huling
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN
| | - Robert A McGovern
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN.,Division of Neurosurgery, Minneapolis VA Health Care System, Minneapolis, MN
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Kemme S, Yoeli D, Sundaram SS, Adams MA, Feldman AG. Decreased access to pediatric liver transplantation during the COVID-19 pandemic. Pediatr Transplant 2022; 26:e14162. [PMID: 34633127 PMCID: PMC8646490 DOI: 10.1111/petr.14162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/15/2021] [Accepted: 09/26/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The COVID-19 pandemic has affected all aspects of the US healthcare system, including liver transplantation. The objective of this study was to understand national changes to pediatric liver transplantation during COVID-19. METHODS Using SRTR data, we compared waitlist additions, removals, and liver transplantations for pre-COVID-19 (March-November 2016-2019), early COVID-19 (March-May 2020), and late COVID-19 (June-November 2020). RESULTS Waitlist additions decreased by 25% during early COVID-19 (41.3/month vs. 55.4/month, p < .001) with black candidates most affected (p = .04). Children spent longer on the waitlist during early COVID-19 compared to pre-COVID-19 (140 vs. 96 days, p < .001). There was a 38% decrease in liver transplantations during early COVID-19 (IRR 0.62, 95% CI 0.49-0.78), recovering to pre-pandemic rates during late COVID-19 (IRR 1.03, NS), and no change in percentage of living and deceased donors. White children had a 30% decrease in overall liver transplantation but no change in living donor liver transplantation (IRR 0.7, 95% CI 0.50-0.95; IRR 0.96, NS), while non-white children had a 44% decrease in overall liver transplantation (IRR 0.56, 95% CI 0.40-0.77) and 81% decrease in living donor liver transplantation (IRR 0.19, 95% CI 0.02-0.76). CONCLUSIONS The COVID-19 pandemic decreased access to pediatric liver transplantation, particularly in its early stage. There were no regional differences in liver transplantation during COVID-19 despite the increased national sharing of organs. While pediatric liver transplantation has resumed pre-pandemic levels, ongoing racial disparities must be addressed.
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Affiliation(s)
- Sarah Kemme
- Section of Gastroenterology, Hepatology, and NutritionDigestive Health InstituteUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColoradoUSA
| | - Dor Yoeli
- Division of Transplant SurgeryColorado Center for Transplantation Care, Research and EducationUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColoradoUSA
| | - Shikha S. Sundaram
- Section of Gastroenterology, Hepatology, and NutritionDigestive Health InstituteUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColoradoUSA
| | - Megan A. Adams
- Division of Transplant SurgeryColorado Center for Transplantation Care, Research and EducationUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColoradoUSA
| | - Amy G. Feldman
- Section of Gastroenterology, Hepatology, and NutritionDigestive Health InstituteUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColoradoUSA
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38
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Bergmark RW, Burks CA, Schnipper JL, Weissman JS. Understanding and Investigating Access to Surgical Care. Ann Surg 2022; 275:492-495. [PMID: 35120062 DOI: 10.1097/sla.0000000000005212] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - Ciersten A Burks
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, MA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit and Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
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39
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Wahid N, Rosenblatt R. Disparities in Telehealth for Liver Disease: Revealing What Was Hidden in Plain Sight. Dig Dis Sci 2022; 67:3-5. [PMID: 33948757 PMCID: PMC8096140 DOI: 10.1007/s10620-021-06996-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Nabeel Wahid
- Department of Medicine, Weill Cornell Medicine, 1305 York Avenue, 4th floor, New York, NY 10021 USA
| | - Russell Rosenblatt
- Department of Medicine, Weill Cornell Medicine, 1305 York Avenue, 4th floor, New York, NY 10021 USA
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40
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Wahid NA, Lee J, Kaplan A, Fortune BE, Safford MM, Brown RS, Rosenblatt R. Medicaid Expansion Association With End-Stage Liver Disease Mortality Depends on Leniency of Medicaid Hepatitis C Virus Coverage. Liver Transpl 2021; 27:1723-1732. [PMID: 34118120 DOI: 10.1002/lt.26209] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/20/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
The Affordable Care Act expanded Medicaid around the same time that direct-acting antivirals became widely available for the treatment of hepatitis C virus (HCV). However, there is significant variation in Medicaid HCV treatment eligibility criteria between states. We explored the combined effects of Medicaid expansion and leniency of HCV coverage under Medicaid on liver outcomes. We assessed state-level end-stage liver disease (ESLD) mortality rates, listings for liver transplantation (LT), and listing-to-death ratios (LDRs) for adults aged 25 to 64 years using data from United Network for Organ Sharing and Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. States were divided into 4 nonoverlapping groups based on expansion status on January 1, 2014 (expansion versus nonexpansion) and leniency of Medicaid HCV coverage (lenient versus restrictive coverage). Joinpoint regression analysis evaluated the significant changes in slope over time (joinpoints) during the pre-expansion (2009-2013) and postexpansion (2014-2018) time periods. We found significant changes in the annual percent change for population-adjusted ESLD deaths between 2014 and 2015 in all cohorts except for the nonexpansion/restrictive cohort, in which deaths increased at the same annual percent change from 2009 to 2018 (annual percent change of +2.5%; 95% confidence interval [CI], 1.8-3.3]). In the expansion/lenient coverage cohort, deaths increased at an annual percent change of +2.6% (95% CI, 1.8-3.5) until 2014 and then tended to decrease at an annual percent change of -0.4% (95% CI, -1.5 to 0.8). LT listings tended to decrease over time for all cohorts. For LDRs, only the expansion/lenient and expansion/restrictive cohorts had statistically significant joinpoints. Improvements in ESLD mortality and LDRs were associated with both Medicaid expansion and leniency of HCV coverage under Medicaid. These findings suggest the importance of implementing more lenient and widespread public health insurance to improve liver disease outcomes, including mortality.
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Affiliation(s)
- Nabeel A Wahid
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY
| | - Jihui Lee
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Alyson Kaplan
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Brett E Fortune
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
| | - Robert S Brown
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Russell Rosenblatt
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
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41
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Lee BP, Dodge JL, Terrault NA. Changes and mediators of survival disparity among Black liver transplant recipients in the United States. Am J Transplant 2021; 21:3883-3893. [PMID: 34374495 DOI: 10.1111/ajt.16767] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 01/25/2023]
Abstract
A landmark 2002 study identified Black liver transplant (LT) recipients as having lower post-LT survival compared to other races. While persistent disparities exist, changes over time and mediating factors are understudied. Capturing LT recipients between 2002 and 2018 in UNOS, we used logistic regression and Cox proportional-hazard models to calculate differences in post-LT mortality among races. We examined interactions between transplant year and race. A mediation analysis assessed biologic and environmental factors potentially associated with race differences in post-LT survival. The cohort included 46,997 LT recipients (3898 Black;36,560 White;6539 Hispanic). In most years, Black (vs. White) LT recipients had a higher probability of age-adjusted mortality, not observed among Hispanics. In multivariable analysis, Blacks (vs. Whites) had higher (aHR = 1.15, 95% CI 1.07-1.24), whereas Hispanics had lower (aHR = 0.78, 95% CI 0.72-0.83) risk of mortality. Differences in post-LT mortality among Blacks (vs. Whites) narrowed between 2002 and 2009, were similar between 2010 and 2013, and may have worsened between 2014 and 2018. Race differences were larger for mortality beyond 1-year post-LT (vs. within 1-year), and among non-HCV (vs. HCV). Alcohol-associated liver disease (ALD) was the strongest mediator (13.9%, 95% CI 8.7-32.7%) of the Black-White disparity in 2010-2018. Our analyses suggest disparities may worsen with longer follow-up, as HCV recedes with elimination efforts, and with further increases in ALD.
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Affiliation(s)
- Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, CA
| | - Jennifer L Dodge
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, CA.,Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA
| | - Norah A Terrault
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, CA
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42
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Rosenblatt R, Lee H, Liapakis A, Lunsford KE, Scott A, Sharma P, Wilder J. Equitable Access to Liver Transplant: Bridging the Gaps in the Social Determinants of Health. Hepatology 2021; 74:2808-2812. [PMID: 34060678 DOI: 10.1002/hep.31986] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 12/17/2022]
Abstract
The COVID-19 pandemic and social justice movement have highlighted the impact of social determinants of health (SDOH) and structural racism in the United States on both access to care and patient outcomes. With the evaluation for liver transplantation being a highly subjective process, there are multiple ways for SDOH to place vulnerable patients at a disadvantage. This policy corner focuses on three different methods to reverse the deleterious effects of SDOH-identify and reduce implicit bias, expand and optimize telemedicine, and improve community outreach.
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Affiliation(s)
- Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Hannah Lee
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA
| | | | - Keri E Lunsford
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.,Center for Immunity and Inflammation, Rutgers New Jersey Medical School, Newark, NJ
| | | | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Julius Wilder
- Division of Gastroenterology, Duke School of Medicine, Durham, NC.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Abstract
PURPOSE OF REVIEW The Final Rule clearly states that geography should not be a determinant of a chance of a potential candidate being transplanted. There have been multiple concerns about geographic disparities in patients in need of solid organ transplantation. Allocation policy adjustments have been designed to address these concerns, but there is little evidence that the disparities have been solved. The purpose of this review is to describe the main drivers of geographic disparities in solid organ transplantation and how allocation policy changes and other potential actions could impact these inequalities. RECENT FINDINGS Geographical disparities have been reported in kidney, pancreas, liver, and lung transplantation. Organ Procurement and Transplant Network has modified organ allocation rules to underplay geography as a key determinant of a candidates' chance of receiving an organ. Thus, heart, lung, and more recently liver and Kidney Allocation Systems have incorporated broader organ sharing to reduce geographical disparities. Whether these policy adjustments will indeed eliminate geographical disparities are still unclear. SUMMARY Modern allocation policy focus in patients need, regardless of geography. Innovative actions to further reduce geographical disparities are needed.
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44
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McClinton A, Gullo J, Martins PN, Serrano OK. Access to liver transplantation for minority populations in the United States. Curr Opin Organ Transplant 2021; 26:508-512. [PMID: 34354000 DOI: 10.1097/mot.0000000000000904] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Racial disparities in access to liver transplantation have been known since the National Transplant Act of 1980. Since the inception of the Final Rule in 2000, the United Network of Organ Sharing has sought to ensure the equitable distribution of donor livers. Despite several measures aimed to improve access for vulnerable populations, disparities in outcomes are still prevalent throughout the liver transplant (LT) evaluation, while on the waitlist, and after liver transplantation. RECENT FINDINGS Blacks and Hispanics are underrepresented on the LT list and have an increased waitlist mortality rate compared to Whites. Additionally, Blacks have a significantly higher risk of posttransplant mortality. SUMMARY Ongoing efforts are necessary to eliminate inequities in transplant access. Strategies such as policy implementation and increasing diversity in the healthcare workforce may prove efficacious in creating change.
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Affiliation(s)
| | - Joy Gullo
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Paulo N Martins
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Oscar K Serrano
- Department of Surgery, University of Connecticut School of Medicine
- Hartford Hospital Transplant & Comprehensive Liver Center, Hartford, Connecticut, USA
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45
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Chiodo Ortiz A, Choubey AP, Pai K, Khan S, Mishra A, Bullock B, Sureddi S, James R, Siddique AB, Koizumi N, Ortiz J. Kidney transplant surgical director training: Urologists represent a functional alternative to general surgeons. Clin Transplant 2021; 35:e14385. [PMID: 34132442 DOI: 10.1111/ctr.14385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/18/2021] [Accepted: 06/02/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Kidney transplant (KT) directors are general surgeons or urologists. All KT centers must meet established performance standards. However, it has not been established if general surgery and urology led programs have disparate outcomes. METHODS Transplant outcomes and donor-recipient characteristics by director training were investigated. Organ Procurement and Transplantation Network (OPTN) directory, program websites were analyzed for surgical director demographics. Scientific Registry of Transplant Recipients (SRTR) 1-year kidney survival and deceased donor (DD) wait-time rankings were evaluated. A retrospective analysis of 142 157 KT recipients from 2010 to 2019 was performed using the United Network for Organ Sharing (UNOS) database. RESULTS One hunderd and seventy three (90.6%) KT programs were led by general surgeons. There were no significant differences in gender, ethnicity, region, credentials, or fellowship completion. Recipients undergoing KT with urology led programs were older (P = .002) and had longer wait-times (P < .001). These centers used higher KDPI (.47 vs. .45, P < .001) and higher HLA mismatch (3.92 vs. 3.89, P = .02) kidneys. Urology led centers utilized living donors less frequently (32.1% vs. 35.8%, P < .001) and had longer CIT (15.44 vs. 12.21, P < .001). Both had similar SRTR ranking of 1-year survival and DD wait-time. CONCLUSION Most directors were general surgeon. Patient outcomes did not differ by transplant director training. Urologists represent a viable option for KT leadership and recruitment should be encouraged.
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Affiliation(s)
- A Chiodo Ortiz
- Department of Surgery, Albany Medical Center, Albany, New York, USA
| | - Ankur P Choubey
- Department of Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - K Pai
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - S Khan
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - A Mishra
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - B Bullock
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - S Sureddi
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - R James
- Schar School of Policy and Government, George Mason University, Fairfax, Virginia, USA
| | - A B Siddique
- Schar School of Policy and Government, George Mason University, Fairfax, Virginia, USA
| | - N Koizumi
- Schar School of Policy and Government, George Mason University, Fairfax, Virginia, USA
| | - J Ortiz
- Department of Surgery, Albany Medical Center, Albany, New York, USA
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